A two-year experience review and comparison of the use of video laryngoscopy and direct laryngoscopy with Bullard, Miller, and Wisconsin blades in pediatric patients undergoing elective surgeries

Background: The use of an appropriate technique for successful and efficient intubation plays a significant role in reducing complications associated with the procedure. Therefore, identifying a standardized method could be highly beneficial. Numerous studies are currently underway worldwide to address this issue. Objective: This study aims to compare direct and indirect laryngoscopy methods in pediatric patients to identify the safest and most effective technique for intubation during elective surgeries. Methods: This parallel cross-sectional and randomizationstudy, conducted at Tehran Children's Medical Center (January 2022–January 2024), aimed to compare direct and indirect laryngoscopy techniques for pediatric intubation during elective surgeries. A total of 144 children aged 2–6 years (ASA I-II) were randomly assigned to four groups: indirect laryngoscopy with a video laryngoscope, and direct laryngoscopy using Bullard, Miller, or Wisconsin blades. Patients with anticipated difficult airways, airway abnormalities, cervical spine injuries, or active pulmonary infections were excluded. Measured parameters included demographic data, intubation duration, time to effective ventilation and vocal cord visualization, Cormack-Lehane grade, success rate, oxygen saturation (including rates of desaturation), and intubation failure rates. All procedures were performed by an experienced anesthesiologist. Statistical analysis was performed using paired t-tests with p<0.05 considered significant. Findings aim to inform the selection of the safest and most effective intubation method for pediatric patients. Result: In this study of 144 pediatric patients (70.8% boys, mean age 3.56±1.22 years), intubation success and timing were compared across four techniques: video laryngoscope, Bullard blade, Miller blade, and Wisconsin blade. The video laryngoscope achieved the highest first-attempt success rate (94.4%) and the shortest times for intubation (17.66±3.52 seconds), ventilation (29±5.24 seconds), and vocal cord visualization (9.47±2.31 seconds), significantly outperforming the other methods (p=0.001 for Bullard, p=0.028 for Miller, p=0.004 for Wisconsin for intubation; p=0.012 for Bullard, p<0.001 for Miller and Wisconsin for ventilation; p<0.001 for all comparisons for vocal cord visualization). Oxygen saturation remained stable across groups. The video laryngoscope demonstrated superior efficiency and effectiveness in pediatric intubation. Conclusion: The findings suggest that video laryngoscopy, when used by an experienced anesthesiologist, significantly reduces intubation time, time to visualize the vocal cords, ventilation time, and the duration of desaturation and related complications. Further research with larger populations and in emergency settings is required to confirm these results.